Influence of effective liver drainage volume on overall survival in patients with malignant hilar biliary obstruction: a multicenter study / 中华消化内镜杂志

Objective:To investigate the influence of liver drainage volume on overall survival time in patients with unresectable malignant hilar bile duct obstruction.Methods:Data of 633 patients with unresectable malignant hilar bile duct obstruction (BismuthⅡ-Ⅳ) who underwent endoscopic stent drainage in 3 endoscopy centers from January 2002 to May 2019 were retrospectively analyzed. Main observation indicators included clinical success rate, stent patency, overall survival, the effective liver drainage volume, and complication incidence.Results:The clinical success rates of patients with liver drainage volume <30%, 30%-50%, and >50% were 56.8% (25/44), 77.3% (201/260) and 84.2% (277/329) respectively. The incidences of early cholangitis were 31.8% (14/44), 18.8% (49/260) and 16.1% (53/329). The median stent patency time was 4.5 (95% CI: 1.8-7.2) months, 5.6 (95% CI: 5.0-6.2) months and 6.6 (95% CI: 5.2-8.0) months. The overall survival time was 2.4 (95% CI: 1.8-3.0) months, 4.0 (95% CI: 3.4-4.6) months and 4.9 (95% CI:4.4-5.4) months, respectively. The clinical success rate ( χ 2=8.28, P=0.012), median stent patency period ( χ 2=18.87, P=0.015) and overall survival time ( χ 2=6.93, P=0.024) of 30%-50% liver drainage volume group were significantly higher than those of <30% group. Further multivariate cox regression analysis showed that the disease type (hepatocellular carcinoma VS hilar cholangiocarcinoma: HR=1.50, 95% CI:1.18-1.91, P=0.001; gallbladder carcinoma VS hilar cholangiocarcinoma: HR=1.45, 95% CI:1.14-1.85, P=0.002; metastatic cholangiocarcinoma VS hilar cholangiocarcinoma: HR=1.48, 95% CI:1.08-2.04, P=0.015), bilirubin level >200 μmol/L ( HR=1.35, 95% CI:1.14-1.60, P<0.001),metal stents ( HR=0.67, 95% CI:0.56-0.79, P<0.001), liver drainage volume (volume 30%-50% VS <30%: HR=0.64, 95% CI: 0.45-0.90, P=0.010; volume>50% VS <30%: HR=0.58, 95% CI:0.41-0.81, P=0.002) and anti-tumor therapy ( HR=0.51, 95% CI:0.42-0.61, P<0.001) were independent predictors for overall survival time of patients with unresectable malignant hilar bile duct obstruction. Conclusion:When endoscopic stent drainage is performed for patients with unresectable malignant hilar bile duct obstruction, at least 30% liver volume is required for better overall survival. In addition, the use of metal stent drainage and anti-tumor therapy may increase survival benefits.

Application value of different metal stents placement position in endoscopic drainage of malig-nant hilar bile duct obstruction: a multicenter study / 中华消化外科杂志

Objective:To investigate the application value of different metal stents place-ment position in endoscopic drainage of malignant hilar bile duct obstruction.Methods:The retro-spective cohort study was conducted. The clinicopathological data of 300 patients with malignant hilar bile duct obstruction who were admitted to 3 medical centers, including 216 patients in the Third Affiliated Hospital of Naval Medical University, 48 patients in the Xijing Hospital of Air Force Medical University, 36 patients in the First People's Hospital Affiliated to Shanghai Jiaotong University School of Medicine, from January 2012 to January 2019 were collected. There were 164 males and 136 females, aged (67±12)years. All patients were determined to be unresectable by multidisciplinary consultation and underwent endoscopic retrograde cholangiopancreatography. Observation indicators: (1) clinicopathological features of patients; (2) follow-up; (3) analysis of influencing factors for patency time of metal biliary stents and overall survival time of patients. Follow-up was conducted using outpatient examination and telephone interview to detect patency of metal biliary stents and survival of patients up to July 2019 or death of patients. Measurement data with normal distribution were represented as Mean± SD, and comparison between groups was conducted using the independent sample t test. Measurement data with skewed distribution were represented as M( Q1, Q3), and comparison between groups was conducted using the Mann-Whitney U test. Count data were expressed as absolute numbers or percentages, and comparison between groups was conducted using the chi-square test or Fisher exact probability. Comparison of ordinal data was conducted using the rank sum test. Kaplan-Meier method was used to calculate survival rates and draw survival curves, and Log-Rank test was used to conduct survival analysis. COX regression model was used for univariate and multivariate analyses. Factors with P<0.1 in univariate analysis were included in multivariate analysis. Results:(1) Clinicopathological features of patients. Of the 300 patients, 163 cases underwent endoscopic drainage with at least one metal biliary stent' distal portion crossing the duodenal main papilla (hereinafter referred to as crossing papilla), and 137 cases underwent endoscopic drainage with no metal biliary stent' distal portion crossing the duodenal main papilla (hereinafter referred to as no crossing papilla). Age, disease type (hilar cholangiocarcinoma, hepatocellular carcinoma, intrahepatic cholangio-carcinoma, gallbladder carcinoma, metastatic cholangiocarcinoma), metal biliary stents type (unilateral metal biliary stent, bilateral metal biliary stents) of patients with crossing papilla were (68±13)years, 95, 8, 11, 31, 18, 63, 100, respectively. The above indicators of patients with no crossing papilla were (64±12)years, 63, 22, 20, 23, 9, 126, 11, respectively. There were significant differences in the above indicators between patients with crossing papilla and patients with no crossing papilla ( t=2.70, χ2=17.69, 90.79, P<0.05). (2) Follow-up. All the 300 patients were followed up for 5.4(3.1,9.3)months. The patency time of metal biliary stents was 9.0(8.2,9.8)months and 6.4(4.8,8.0)months of patients with crossing papilla and patients with no crossing papilla, showing a significant difference between them ( χ2=8.23, P<0.05). The overall survival time was 5.5(4.2,6.8)months and 5.5(4.3,6.8)months of patients with crossing papilla and patients with no crossing papilla, showing no significant difference between them ( χ2=0.28, P>0.05). (3) Analysis of influencing factors for patency time of metal biliary stents and overall survival time of patients. Results of univariate analysis showed that type of metal biliary stents and the placement position of metal biliary stents were related factors affecting the patency time of metal biliary stents [ hazard ratio( HR)=0.44, 0.60, 95% confidence intervals as 0.30?0.64, 0.42?0.85, P<0.05]. Results of multi-variate analysis showed that bilateral metal biliary stents was an independent protective factor for the patency time of metal biliary stents ( HR=0.46, 95% confidence interval as 0.29?0.72, P<0.05). Results of univariate analysis showed that disease type (intrahepatic cholangiocarcinoma versus hilar cholangiocarcinoma), preoperative serum total bilirubin, type of metal biliary stents, anti-tumor therapy were related factors affecting the overall survival time of patients ( HR=1.05, 1.43, 0.72, 0.61, 95% confidence intervals as 0.70?1.57, 1.12?1.83, 0.55?0.92, 0.47?0.81, P<0.05). Results of multi-variate analysis showed that age >60 years, disease type as hepatocellular carcinoma, preoperative serum total bilirubin >200 μmol/L were independent risk factors for the overall survival time of patients ( HR=1.35, 1.98, 1.46, 95% confidence intervals as 1.02?1.79, 1.40?2.80, 1.13?1.89, P<0.05), and bilateral metal biliary stents, anti-tumor therapy were independent protective factors for the overall survival time of patients ( HR=0.68, 0.60, 95% confidence intervals as 0.53?0.89, 0.45?0.80, P<0.05). Conclusions:Endoscopic drainage with or without metal biliary stents' distal portion crossing the duodenal main papilla is safe and feasible for patients with malignant hilar bile duct obstruction. Bilateral metal biliary stents is an independent protective factor for the patency time of metal biliary stents. Age >60 years, disease type as hepatocellular carcinoma, preoperative serum total bilirubin >200 μmol/L are independent risk factors for the overall survival time of patients, and bilateral metal biliary stents, anti-tumor therapy are independent protective factors for the overall survival time of patients.

Application value of digital single-operator peroral cholangioscopy on the preoperative evalua-tion of extrahepatic cholangiocarcinoma / 中华消化外科杂志

Objective:To investigate the application value of digital single-operator peroral cholangioscopy on the preoperative evaluation of extrahepatic cholangiocarcinoma.Methods:The propensity score matching and retrospective cohort study was conducted. The clinicopathological data of 172 patients with extrahepatic cholangiocarcinoma who were admitted to the First Affiliated Hospital of Army Medical University from December 1, 2017 to April 1, 2022 were collected. There were 91 males and 81 females, aged 65(range, 45?68)years. Of 172 patients, 36 cases undergoing preoperative digital single-operator peroral cholangioscopy examination were allocated into the experimental group, and 136 cases not undergoing preoperative digital single-operator peroral cholangioscopy examination were allocated into the control group. Observation indicators: (1) propensity score matching and comparison of general data of patients between the two groups after matching; (2) surgical conditions. Propensity score matching was done by the 1:1 nearest neighbor matching method and caliper setting as 0.02. Measurement data with normal distribution were expressed as Mean± SD, and t test was used for comparison between groups. Measurement data with skewed distribution were expressed as M( Q1,Q3), and the Mann-Whitney U test was used for comparison between groups. Count data were expressed as absolute numbers or percentages, and comparison between groups was analyzed using the chi-square test or Fisher exact probability. The rank sum test was used for comparison of ordinal data. Results:(1) Propensity score matching and comparison of general data of patients between the two groups after matching. Of 172 patients, 60 cases were successfully matched, including 30 cases in the experiment group and 30 cases in the control group, respectively. Before propensity score matching, cases with or without preoperative bile drainage were 27, 9 in the experiment group, versus 62, 74 in the control group, showing a significant difference between the two groups ( χ2=9.86, P<0.05). The above indicators were 23, 7 in the experiment group, and 23, 7 in the control group after propensity score matching, showing no significant difference between the two groups ( χ2=0.00, P>0.05). The elimination of preoperative bile drainage confounding bias ensured comparability between the two groups. (2) Surgical conditions. After propensity score matching, there were 10 cases and 0 case without surgery in the two groups. Cases undergoing radical operation including R 0, R 1, R 2 resection were 16, 0, 4 in the experiment group, versus 18, 6, 6 in the control group, showing a significant difference between the two groups ( χ2=6.85, P<0.05). Conclusions:Preoperative digital single-operator peroral cholangioscopy exami-nation can improve the R 0 resection rate of extrahepatic cholangiocarcinoma.

Application of percutaneous transhepatic cholangial drainage in the treatment of bile duct obstruction with malignant hilar bile duct carcinoma / 局解手术学杂志

Objective To analyze the therapeutic effect of percutaneous transhepatic cholangial drainage (PTCD) in the treatment of bile duct obstruction in patients with malignant hilar bile duct carcinoma,and to discuss the clinical application and practical value of PTCD.Methods A total of 55 patients with malignant biliary obstruction were divided into the PTCD group (30 cases who recieved percutaneous transhepatic cholangial drainage) and the control group (25 cases who recieved endoscopic stent implantation).Observed the preoperative and postoperative biochemical indexes of PTCD group,including serum total bilirubin (TB),serum direct bilirubin (DB),serum alanine aminotransferase (ALT) and serum glutamic acid amino turn shift of aspartate aminotransferase(AST) and serum alkaline phosphatase(AKP).Compared the effect rate and postoperative survival time of the two groups through postoperative follow-up.Results The TB,DB,ALT,AST and APK of PTCD group one week after operation changed obviously compared with the relative index before opreation with statistically significant differences (P<0.05), which indicated a significant improvement of biochemical indicators.The treatment efficiency of the PTCD group and the control group were 83.3% and 64.0% respectively, and survival time of the two groups were(7.5±2.6)months and(4.8±2.8)months respectively.Results of the PTCD group was significantly better than that of the control group,and the differences were statistically significant(P<0.05).Conclusion All the patients with PTCD get better biochemical indicators and longer postoperative survival time,and the interventional therapy PTCD can be used as an effective clinical treatment method for bile duct obstruction with malignant hilar bile duct carcinoma.

The Experiment Research of Plastic Anastomosis in Treatment of Benign Stricture of Hilar Bile Duct / 昆明医科大学学报

Objective To explore a new technique to treat the benign stricture at hilar bile duct of plastic anastomosis, so as to obtain the theoretical basis and the feasibilities of practical application in treating the benign stricture at hilar bile duct with plastic anastomosis through the animal experiments. Methods 30 miniature pigs were randomly divided into three groups. Group A (control group):2 centimeters of the bile duct above the duodenum was isolated;Group B:The same separation of bile duct with group A, then making physical injury on it with the clamps and electric heat;Group C:Making bile duct injury model in group C as group B,and then monitoring of the diet, feces, urine, ALT, AST and bilirubin etc. When the bile duct stricture was formed, taking the plastic anastomosis operation in this group. After all the operations, we observed the diet, mental state and the color of the urine of animals in all the three groups, and tested ALT,AST,T-BIL and D-BIL levels on the pre- and post-day and every 7 days after surgery respectively. After three months of the surgery,we executed all the pigs,picked up part of the liver tissue,then preserved them by liquid nitrogen for pathological examination. Results From the day before operative-day to the 30 days after operation, there was no significant change in ALT, AST, T-BIL and D-BIL in group A,while the relative indicators of group B and C had obvious changes ( <0.05) . The indicators of group B were significantly increased 21 days after surgery, compared with pre-operation and 14 days after operation respectively ( <0.05) . In group C, the indicators were significantly declined 14 to 21 days after the plastic anastomosis compared with pre-operation (<0.05) . Conclusions Treating benign stricture at hilar bile duct of miniature pigs by plastic anastomosis is feasible and practicable. This study provides an experimental basis for clinical application of plastic anastomosis in treatment of benign stricture at hilar bile duct.

Clinical study of 223 cases of hilar cholangiocarcinoma / 中国现代普通外科进展

Objective:To valuate the relationships between operation modus,pathological characteristics and the prognosis on hilar cholangiocinoma(HCC). Methods:The clinical features,diagnostic methods,operation modus and histopathology results of the 223 cases with HCC were analyzed retrospectively. Results:1) Radical excision had been performed in 85 cases with the excision rate of 38.1%,1,3,5 years survival rates were 58.8%,30.9%,8.8% respectively. Palliative therapy had been performed in 110 cases; the median life span was 8 months. The average life span of those who had given up treatment was about 5 months. 2) In 132 cases of HCC,121 cases were adenocarcinoma,accounting for 91.7%. Well-differentiated was 29 cases (24.0%),medium-differentiated was 43 cases (35.5%),and poor-differentiated was 49 cases(40.5%). The others accounted for 8.3%,in total. The 1,3,5 years survival rate after radical excision of the well-differentiated and the medium-differentiated groups were 55.0%,40.0% and 15.0% respectively,those of the poor-differentiated group were 45.8%,16.7% and 0% respectively. 3) According to the Bismuth Corlette grouping type I was 20.1%,type II was 23.2%,type IIIa was 10.3%,type IIIb was 23.2%,type IV was 7.2%,and the others were 16.0%. Conclusions:1)Radical excision is the key to raise the long-term survival rate. The average life span of those who had given up treatment was about 5 months,which can reflect the natural life span. 2) Poor-differentiated adenocarcinoma accounted for considerable proportion in histopathology types of the hilar cholangiocarcinoma. 3)Bismuth Corlette grouping has some certain limit and disadvantages in the application.

Analysis of Long-Term Survivors after Resection for Hilar Bile Duct Cancer

PURPOSE: Although considerable progress has been made in the management of hilar bile duct cancer, the long-term outlook for most patients remains poor. This study was conducted to analyze the long-term survival (more than 5 years) after resection for hilar bile duct cancer focusing on the clinicopathological factors influencing the outcome, and to develop an optimal strategy to achieve long-term survival after a resection. METHODS: A retrospective review was performed for 68 patients with hilar bile duct cancer who underwent surgical resection between 1988 and 2000. Survival rates and prognostic factors were assessed. Clinical and pathological factors of patients who survived more than 5 years were compared with patients whose survival was less than 5 years. Clinicopathological features characterizing the long-term survivors were also reviewed. RESULTS: Seventeen patients survived longer than 5 years after resection. The actual 5-year survival rate was 25.0%. Perineural invasion and resection margin were identified as independent prognostic factors. When prognostic factors were compared between the long-term and short-term survivors, tumor depth, TNM stage, perineural invasion, and resection margin showed a significant correlation with long- term survival. Long-term survivors had early TNM stages with negative lymph node metastasis and absence of perineural invasion. Six of 17 long-term survivors exhibited a positive resection margin. CONCLUSION: Long-term survivors showed characteristic features of early TNM stages with absence of perineural invasion and negative resection margin. As long-term survival can be expected even in patients with bad prognostic factors, aggressive surgical resection should be attempted for patients with resectable disease.

Impact of External Beam Radiotherapy after Surgical Resection for Hilar Bile Duct Carcinoma

PURPOSE: For bile duct carcinomas, local treatment including surgical resection plays an important role. In the case of hilar bile duct carcinoma, the rate of resection is low and local recurrences are frequent, even after radical resection. Radiotherapy, one of the local remedies, may influence the treatment result. The aims of this study were to determine the effect of radiotherapy after surgical resection on the length of survival, as well as the radiation toxicity, in patients with hilar bile duct carcinoma. METHODS: Seventy patients with hilar bile duct carcinoma were included in this study; 46 underwent surgical resection only while 24 additionally received external beam radiotherapy after resection. The authors compared the survival rate between the two groups and investigated the complications following radiotherapy. RESULTS: The overall 5-year survival rate after surgical resection was 28.3%; 20.1% and 31.3% in patients with and without radiotherapy, respectively. The difference was not significant (P> 0.10). In patients with positive surgical margin, the 5-year survival rate for the radiation group was superior to that of the non-radiation group (21.8% vs. 10.1%), but aqain the difference was not statistically significant (P> 0.10). In patients with lymph node metastasis the survival rates for radiation and non-radiation groups showed no significant difference(median survival, 7 vs. 13 months) (P> 0.10). Leukopenia (n=2) and digestive complications including gastroduodenal ulcers (n=2) occurred after radiotherapy. CONCLUSION: External beam radiotherapy after radical resection had no significant effect on the length of survival in patients with resectable hilar bile duct carcinomas.

Isolated Caudate Lobectomy with Bile Duct Resection Performed in a Patient with Type IV Hilar Bile Duct Cancer

The prognosis of hilar bile duct cancer has been improved by extensive curative resection, but limited functional reserve of the liver occasionally does not permit such a major hepatectomy. We report a type IV hilar bile duct cancer case undergone isolated caudate lobectomy as a limited but curative resection, in whom the indocyanine green retention test at 15 minutes revealed 23.9% despite long-term biliary decompression and the whole liver was rather atrophic. Complete removal of the Spiegel lobe, paracaval portion, and caudate process combined with hilar bile duct resection made 3 right and 4 left intrahepatic duct openings, which were reconstructed as a whole at each side of transection plane after ductoplasty. The patient recovered uneventfully. Although surgical technique for isolated caudate lobectomy must be more difficult comparing with other anatomical hepatectomy, but it can be a ultimate technique of limited curative resection for advanced hilar bile duct cancer patients with decreased hepatic reserve. Comprehension to the anatomy of the caudate lobe is a prerequisite for its resection, thus we discussed it in detail.

S4a+S5 with Caudate Lobe (S1) Resection as a Parenchyma-preserving Liver Resection for a Patient with Type IIIb Hilar Bile Duct Cance

The prognosis of hilar bile duct cancer has been improved by extensive curative resection, but massive hepatectomy can result in surgical and medical complications in high-risk patients. We report a case of type IIIb hilar bile duct cancer undergone S4a S5 with caudate lobe (S1) resection as a parenchyma-preserving hepatectomy. The operation was a modified type of Taj Mahal liver resection omitting parencymal transection between S4b and S8. Such an extent of hepatectomy combined with bile duct resection made 3 right and 3 left intrahepatic segmental duct openings, which were reconstructed as a whole at each side of transection plane after ductoplasty. The patient recovered uneventfully. Although surgical technique for S4a+S5+S1 must be more complex comparing with other anatomical hepatectomy, but it could be accepted as a safe curative resection for some selected patients with advanced hilar bile duct cancer, by which favorable recovery of the liver function may lead to prevention of postoperative complications. Comprehension to the anatomy of the intrahepatic ducts is a prerequisite for S4a+S5+S1 resection, thus we discussed it in detail.

Percutaneous transhepatic portal embolization for hilar cholangiocarcinoma / 中国微创外科杂志

Objective To assess the clinical efficacy of percutaneous transhepatic portal embolization (PTPE) before the extended right hemihepatectomy for the treatment of hilar cholangiocarcinoma. Methods We successfully carried out a percutaneous transhepatic portal embolization in a patient with hilar cholangiocarcinoma and liver cirrhosis. Hepatic hemodynamics, liver volume,liver functions, and pathological changes were recorded after the procedure. Results After PTPE, the patient developed an inflammatory response manifested by a transient fever (39.2 ℃ at peak on the 5th postoperative day) and a mild abdominal pain. There were no other complications such as nausea, vomitting, hemorrhage, or bile leakage. The volume of the left lobe increased from 417.0 ml to 522.4 ml (enlargement rate, 125.2%); the volume of the right lobe decreased from 1041.3 ml to 1017.4 ml (diminishment rate, 97.7%). The ratio of the left lobe to the whole liver increased from 28.6% to 33.9%. The velocity of blood flow of the left portal vein increased by 100% and 39% on the day of operation and the 6th day after operation, respectively (from 12.8 ml/s preoperatively to 23.2 ml/s and 17.1 ml/s). The values of ICG R15 and ICG-K returned to normal levels. On the 17th day after PTPE, the quantity of bile drainage from the left lobe exceeded that from the right lobe. The extended right hemihepatectomy was performed 34 days after PTPE. During operation, an obvious hypertrophy of the left lobe and a distinct demarcation line between the segment 5, 6, and 7 (S5,6,7) and other segments were observed. Postoperative recovery was uneventful. The pathological examination found stenosis and embolization of the portal vein, as well as the degeneration, necrosis, and apotosis of the liver cells in the embolized lobe. Conclusions Portal vein embolization can effectively induce the hypertrophy of the unembolized lobe, which increases the safety level of following extended hemihepatectomy in patients with impared liver functions.

Clinical Outcome of Major Hepatobiliary Resections for Malignant Tumor of the Extrahepatic Biliary Tree

PURPOSE: A major hepatobiliary resection (MHBR), liver resection of more than one lobe, has been recommended by some surgeons for advanced carcinomas (Ca) of the gallbladder (GB) and the hilar bile duct (HBD). However, high operative mortality and morbidity have been reported and its survival benefit has not been clearly documented. METHODS: We report the results of MHBR for such tumors to determine the safety and the effectiveness of this operation, which has been performed for GB Ca invading the right hepatic pedicle or liver bed by 2 cm or more and for HBD Ca of Bismuth type III or IV. The cases of fifty consecutive cases who received MHBR for GB Ca (n=11) or HBD Ca (n=39) during a 5 year-period were reviewed. RESULTS: Thirty right-sided and 20 left-sided hepatectomies were performed. There was no operative or hospital death. Minor and major complications developed in 64% of the cases. All the complications improved with conservative management, except two in which re operations were required, one due to portal vein thrombosis and the other to bleeding of the retro peritoneal dissection site. No specific factors were associated with the high complication rate. The long-term outcome of HBD Ca was better than that of GB Ca. In HBD Ca, differentiated cancer and less transfusion were associated with a better prognosis. CONCLUSION: MHBR was conducted with acceptable morbidity and no mortality. In terms of the long-term outcome, MHBR is recommended for HBD Ca whereas it should be considered more carefully for GB Ca.

Clinical Outcome of Major Hepatobiliary Resections for Malignant Tumor of the Extrahepatic Biliary Tree

PURPOSE: A major hepatobiliary resection (MHBR), liver resection of more than one lobe, has been recommended by some surgeons for advanced carcinomas (Ca) of the gallbladder (GB) and the hilar bile duct (HBD). However, high operative mortality and morbidity have been reported and its survival benefit has not been clearly documented. METHODS: We report the results of MHBR for such tumors to determine the safety and the effectiveness of this operation, which has been performed for GB Ca invading the right hepatic pedicle or liver bed by 2 cm or more and for HBD Ca of Bismuth type III or IV. The cases of fifty consecutive cases who received MHBR for GB Ca (n=11) or HBD Ca (n=39) during a 5 year-period were reviewed. RESULTS: Thirty right-sided and 20 left-sided hepatectomies were performed. There was no operative or hospital death. Minor and major complications developed in 64% of the cases. All the complications improved with conservative management, except two in which re operations were required, one due to portal vein thrombosis and the other to bleeding of the retro peritoneal dissection site. No specific factors were associated with the high complication rate. The long-term outcome of HBD Ca was better than that of GB Ca. In HBD Ca, differentiated cancer and less transfusion were associated with a better prognosis. CONCLUSION: MHBR was conducted with acceptable morbidity and no mortality. In terms of the long-term outcome, MHBR is recommended for HBD Ca whereas it should be considered more carefully for GB Ca.

Techniques and Indications for a Central Bisegmentectomy of the Liver

BACKGROUND: Central bisegmentectomy (CBS) of the liver is a resection of the medial and anterior segments for preserving more liver parenchyma and reaching the goal of a curative resection simultaneously. PURPOSE: In this paper, we describe the indications and the techniques for this surgical procedure. PATIENTS AND METHODS: We reviewed the case histories of 14 patietns who had undergone a CBS, including 9 with a hepatocellular carcinoma, 4 with hilar bile-duct cancer, 1 with metastatic colon cancer, and 1 with gallbladder cancer. Eight patients had undergone a CBS with an operating time of only 353 minutes; 5 cases had undergone a CBS and a caudate lobectomy plus bile-duct resection, requiring an operating time of 762 minutes. A hepaticojejunostomy to right posterior hepatic duct was added to one CBS case because of intrahepatic ductal variation. The surgical technique for the CBS only procedure was as follows: demarcation of the dissection line with a selective block of the glissonian cord, division of the medial and the lateral segments along the falciform ligament to expose the left hepatic vein, and division of the anterior and the posterior segments along the right hepatic vein. In the combined bile-duct-resection cases, complete dissection of the hepatoduodenal ligament and biliary reconstruction were added. RESULTS: The extent of liver resection, as estimated by CT volumetry, was about 42%, and the mean value of the real weights of the specimens was 474 gm. The preoperative hepatic function showed a 9.3% indocyanine-green retention rate at 15 minutes, and 5 out of 9 hepatocellular carcinoma cases revealed concomitant liver cirrhosis. For CBS and additional procedures, the curative resection rate reached 93%, and the survival rate was favorable. There were no operative mortalities or hepatic failures. CONCLUSIONS: For selected cases of centrally located liver tumors or hilar bile-duct cancer with limited hepatic reserve, CBS may provide a safe, curative resection.

Long-term Result of Radical Resection for Hilar Bile Duct Cancer

Sixty patients with hilar bile duct cancer were operated on during a period of nine years. The tumor was resected in 45 patients (resection rate:75.0%). A hilar resection with regional lymph-node dissection was performed in 27 patients, and various types of hepatic resections were added in 18 patients. A potentially curative resection was achieved in 20 patients (curative resection rate:44.4%). There were two operative deaths (operative mortality:4.4%). The overall cumulative five-year survival rate was 25.6%. Six patients survived for more than five years. The survival was superior in patients with a curative resection and in those with a combined hepatic resection, but this result was statistically insignificant. Regional lymph-node metastasis, gross type, histologic grade, and perineural invasion were significant prognostic factors. We conclud that improved survival in hilar bile duct cancers can be achieved by a radical resection with acceptable morbidity and mortality.